Provider Demographics
NPI:1780227850
Name:HICKMAN, ELISA MARIE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:MARIE
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 KRUGER ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-5126
Mailing Address - Country:US
Mailing Address - Phone:304-905-8142
Mailing Address - Fax:
Practice Address - Street 1:403 KRUGER ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5126
Practice Address - Country:US
Practice Address - Phone:304-905-8142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009442001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical